23 year-old British Caucasian university student felt some gland swelling at her neck. Upon further questioning, she reports on and off fever with overnight sweating, and noticed 7 kg weight loss. She travelled to Malaysia, Thailand and Hong Kong 6 months previously. BCG vaccination has been obtained. On examination, there is palpable rubbery cervical lymphadenopathy. Subsequent chest X ray uncovers increased mediastinal opacity and enlargement.
What is the differential diagnosis and course of action?
DDx:
ReplyDelete1) Lymphoma (unspecified)
2) Sarcoid
3) TB
peace out!!!
The patient is young,female with a list of constitutional symptoms. She also has a history of foreign travel. It would've been useful to know if the palpable Lymph Node was tender or not.
ReplyDeleteDDX:
1) Hodgkin's Lymphoma
2)non-Hodgkin's Lymphoma
3) TB
Given the course I'd veer on the side of caution and assume the worst.
Investigations:
-FBC----> Check for anaemia and White Cell figure derangement
- ESR and CRP (not that useful)
-Acid-Fast stain----> for TB
-Biopsy the node (If Lymphoma with Reed-sternberg then Hodgkin's, if not then Non-Hodgkin's)
Management:
Lymphoma----->Refer to Oncologist for chemo
TB-----> RIPE Acronym: Rifampacin, Isoniazide, Pyrazinamide and Ethambutol (Warn patient about any visual disturbances and changes of urine color)
I couldn't agree more !! Hodgkin's lymphoma (HL) is the working diagnosis - the most common type of HL is nodular sclerosing HL which accounts for 70% of cases. It occurs in young females and usually presents as painless rubbery lymphadenopathy with breathlessness or cough by means of airway obstruction due to mediastinal lymph node involvement.
ReplyDeleteInfection is less likely due to the 6-month gap between travel and development of clinical features (please note that BCG is a red herring - although UK trials showed efficacy between 60-80%, other studies in US and India yielded efficacy rates as low as 14% or even 0 respectively).
Sarcoidosis is another possibility due to possible hilar lymph node involvement although acute sarcoid usually presents with erythema nodosum with/without polyarthralgia and in about 20-40% cases it's incidental finding due to abnormal CXR
Lymph node biopsy is the single most important and informative investigation to test the suspicion of malignancy
P.S. sorry for lack of details -meant to make it more challenging !!